Horizons | Research Update | Mobilizing Young People for the Care and Support of People Living with HIV/AIDS in Zambia

Mobilizing Young People for the Care and Support of People Living with HIV/AIDS in Zambia

The prevalence of HIV infection among young Zambians ages 15 to 20 years is estimated to be 20 percent, with females five times more likely to be infected as males. As the threat to young people grows, the care and support needs of people living with HIV/AIDS (PLHA) and orphans and vulnerable children (OVC) are also escalating.

Many young people are already providing care to sick family members, although few have the appropriate knowledge and skills to deal with the complex health needs and social issues associated with HIV/AIDS, such as stigmatization. Training young people as caregivers and as agents of stigma reduction may help communities cope better with the impact of HIV/AIDS and help motivate young people to practice protective behaviors.

One promising development in Zambia has been the growth of hundreds of anti-AIDS clubs for young people based in schools and the community. Anti-AIDS clubs organize and conduct recreational activities, especially football and netball games, drama, red ribbon campaigns, and community outreach.

These clubs—staffed by adolescent volunteers who act as role models and peer educators—are the focus of an intervention study conducted by Care International, Family Health Trust, and Horizons. The study seeks to determine which care and support needs of PLHA and their families can be met by trained youth, and whether youth engaged in care and support activities reduce risky behaviors as well as become community advocates for PLHA and OVC. The quasi-experimental study is being conducted in two semi-urban/rural provinces. Thirty clubs in two districts in Luapula Province, serve as intervention sites; an equal number in two districts in Northern Province serve as control sites. Club members and patrons from all 60 clubs receive training in HIV/AIDS prevention and club management, yet only the intervention clubs in the two Luapula districts receive training, materials, and ongoing support for caring for PLHA and OVC (Figure 1). The clubs participating in the study include both well-established and newly formed ones.

The study began by collecting qualitative data from young people about their attitudes toward risky and prevention behaviors, PLHA and OVC, and youth involvement in care and support activities. The researchers also solicited the views of community members on care for PLHA by youth. After the HIV prevention and club management workshops, youth members from a random sample of 16 of the 30 intervention clubs and 16 of the 30 control clubs completed an interviewer-administered questionnaire. Half of the clubs in each group (intervention and control) are school based and the other half are community based. All respondents will be surveyed again one year after completion of the care and support training for the intervention clubs in Luapula Province. The researchers are also collecting process data at the club level and qualitative data from youth and adults points during the study.

This summary presents key findings from the study to date, including results from the first questionnaire administered to club members and workshops with club members and others to discuss the data from the questionnaire.¹ The questionnaire sample consists of a total of 785 club members, 391 males and 394 females from 12 to 23 years old. Almost all respondents are single; nearly two-thirds are 15 to 19 years old. Ninety-seven percent of males and females ages 12 to 16 are in school, and most older respondents ages 17 to 23 years also attend school (82 percent of females, 74 percent of males). Only about half of the sample lives with both mother and father. About a third of males and more than a fourth of females live with a non-parent.

Although twice as many male as female club members report ever having sex, both groups tend to have sex intermittently and with only one partner.

Overall, 79 percent of males and 40 percent of females have had sexual intercourse. Examining sexual experience by age (Figure 2), more than twice as many males as females ages 12 to 16 years reported having had sex (67 percent vs. 28 percent). While the figures for older males and females are closer (86 percent vs. 56 percent), the proportion of males 17 to 23 years old who reported sexual intercourse is still much greater than comparably aged females.

Regardless of age, however, club members are having sex irregularly. The vast majority of sexually experienced males and females did not have sex in the last three months (Table 1). A small proportion of males (13 percent) and a much smaller percentage of females (2 percent) who had had sex did so with more than one partner in the last three months. Few males (8 percent) and females (4 percent) reported consuming alcohol prior to having sex in the last three months.

When these findings were discussed with club members, some males and females felt that young women underreported their sexual activity because of cultural taboos against speaking openly about your sexual life. However, others believed that the findings were correct because young men tend to draw their partners from a small sub-group of female peers and sex workers. Club members also felt that the results reflect their tendency to have sex with one person, but not those of young people uninvolved in club activities whom, they believe, have a greater number of sexual partners.

Reported condom use by male and female club members is relatively high, particularly among older club members. More than half of all sexually experienced club members had ever used a condom. There was little difference between ever use of condoms by males (56 percent) compared to females (54 percent). Not surprisingly, use of condoms increased with age: about two thirds of older males and females (aged 17 to 23 years) reported ever use of a condom (Table 1). A high proportion of all respondents who had used a condom did so in their last sexual encounter (86 percent of males and 82 percent of females). Although a similar proportion of females and males have used condoms, the vast majority of both groups feel that it is the man’s responsibility to provide the condom. Only 18 percent and 19 percent of males and females, respectively, feel it is the responsibility of either partner.

During the data interpretation workshops, it was difficult to get a clear picture of how these findings reflect actual condom use by club members. Many felt that there is growing interest in and demand for condoms and that young people in particular appreciate the need to use them. Some clubs obtain free condoms from the public health sector which they distribute to members and the community. However, only some of those present at the workshop were sure of where to buy or obtain free condoms, especially those living in very rural areas. This observation calls in to question the fairly high reported rates of condom use.

While the majority of male and female club members believe that women are more vulnerable to HIV, they disagree about who is responsible for spreading the disease. When asked who is more vulnerable to HIV infection, the majority of both sexes said that females are. Interestingly, males perceived female vulnerability to be greater than females did (66 percent vs. 54 percent). But when asked who is more responsible for spreading HIV/AIDS, 65 percent of females felt that boys and men are compared to only 41 percent of males. More than half of males (56 percent) blamed females for spreading the disease.

During the data interpretation workshops, males blamed females and females blamed males for spreading HIV. Some youth said that the difference in opinion reflects the lack of trust that characterizes the nature of relationships between girls and boys.

¹ These workshops included participation of club members, adult club patrons, and stakeholders, such as representatives of the District AIDS Task Force, Ministry of Community Development and Social Welfare, Ministries of Education and Health, Catholic Archdiocese, Planned Parenthood Association of Zambia, and other NGOs.

Most club members feel they have little or no chance of getting infected with HIV. More than two-thirds of males (68 percent) and three-fourths of females (77 percent) believe they have no risk of HIV infection. An additional 19 percent of males and 13 percent of females feel they have only a small chance of getting the disease. When asked why, those females with little or no risk perception tended to give abstinence or never having sex as their reason, while most males mentioned sticking to one partner or using condoms consistently as responses. For the small proportion of respondents who felt they had a moderate or great chance of getting HIV/AIDS (males 11 percent, females 9 percent), there was as much concern about blood transfusions, injections, and sharp instruments as there was about multiple sexual partners and not using condoms.

Club members who attended the data interpretation workshops concurred with the finding about respondents’ perception that they are at little or no risk of HIV infection. However, they believed that the majority of young people who are not club members are at high risk of infection and do not recognize their risk. Therefore, workshop participants noted that there is an urgent need to help these youth acquire the skills and knowledge to accurately assess their risk of HIV/AIDS.

Male as well as female club members experience pressure to have sex and are involved with exchanging sex for money or gifts. About 40 percent of both males and females reported facing pressure by peers to do something they did not want to do. About half of these respondents felt pressure to do something sexual, which was twice as high as other responses, including drinking and staying out late. When asked directly about being verbally or physically forced or threatened to have sex, 4 percent of males and 7 percent of females acknowledged this experience. While more than a fourth (28 percent) of all males had given something in exchange for sex, the questionnaire also revealed that 9 percent of males, in addition to 15 percent of females, received gifts or money in exchange for sex. Very few (around 1 percent) of males and females said they had sex with someone ten or more years older.

Workshop participants acknowledged the role of peer pressure and more extreme forms of verbal and physical force on the sexual experiences of young people. That males also exchange sex for gifts and money came as a surprise for many workshop participants.

The vast majority of club members would be comfortable providing care to PLHA, and nearly half have already helped care for someone who was chronically ill. Both males and females agree that PLHA deserve compassion and support (86 percent). When asked about their comfort level around PLHA, more than 90 percent of club members said they would be comfortable working with PLHA or shaking their hands. A smaller proportion, yet still the vast majority, said they would feel fine about providing care/support to a person with AIDS (79 percent for males and 73 percent for females). Interestingly, 47 percent of males and 42 percent of females said they have provided care to a family member or other person who was chronically ill in the last six months.

Despite overall support for assisting with caregiving, club members identified a number of concerns. These include a lack of skills, training, and transport, and a fear that parents and church leaders might react negatively. For example, parents would be concerned that caregiving would pull youth away from school and other work, and church groups would associate PLHA with promiscuity. Some club members also wondered about how confidentiality would be addressed and how older PLHA would feel about youth involvement. With regard to specific tasks, males and females agreed that both could help PLHA with washing clothes and going to the toilet, encouraging them to eat, fetching water, and buying medicine, as well as just sitting and talking with them. In addition, they thought that club members could conduct village-wide education on HIV/AIDS and PLHA. However, club members did feel that advising on risky behaviors is more suited for males, while helping PLHA with domestic chores like cooking and cleaning are more appropriate for girls.

Training youth and enlisting the support of club patrons, medical professionals, and village heads is crucial for youth involvement in PLHA caregiving. Club members from the 30 clubs in Luapula Province, the intervention arm of the study, participated in care and support training workshops and follow-up field training activities. The training curriculum covered such topics as stigma and serostatus disclosure, gender roles and caregiving, children’s rights, HIV/AIDS-related conditions, HIV testing and counseling, community services and referral, community and home-based care, and monitoring club activities. Each club received ten kits containing such basic materials as aprons, soap, salt, disinfectant, gloves, cotton wool, bandages, notebooks, pens, and monitoring forms. Club members and patrons also received training on how to facilitate youth care-giving activities by soliciting support from adult caregivers, home-based care groups, health clinic staff, village chiefs, and leaders.

Six months after the training, all clubs reported that they are providing care for between four and twelve PLHA and are sharing their knowledge and skills with family members. Both male and female club members prefer to perform tasks for same-sex clients that are in line with prevailing gender role expectations. Clubs also reported encouraging OVC to join club activities and to become members, as well as conducting community education on the rights of OVC. Support from health care professionals and village leaders has proven to be crucial for linking youth care-givers to PLHA and for gaining community acceptance of their role as caregivers.

Conclusion

The findings show that club members, while not a particularly high-risk group overall, nevertheless include males and females who report behaviors and experiences, such as unprotected sex and forced sex, that place them at risk of HIV. Data on sexual coercion of club members and exchanging sex for money highlight the need to address these difficult issues in any HIV prevention program that targets both males and females. In addition, such programs need to examine how gender stereotypes prevent males and females from taking equal responsibility for condom use and other forms of HIV prevention and feed mistrust in relationships.

Workshop-based and hands-on field training activities are proving to be effective in building the capacity of youth caregivers. Critical to the utilization of this capacity is the development of support for youth involvement in caregiving by club patrons, village leaders, and health professionals in order to establish links with households affected by HIV/AIDS and to give credibility to young peoples’ new role as caregivers. Also crucial is the regular replenishment of supplies in the caregiving kits.

Finally, given that nearly half of club members have already been called upon to provide care to someone chronically ill, it is important that youth prevention programs in high HIV prevalence areas address care as well as prevention in order to help young people perform caregiving tasks as safely and effectively as possible.

Next Steps

The researchers are finalizing the collection and analysis of the club-level process data, the interview data, and the results from the follow-up questionnaire. A final report of the study findings will be available by late 2002.

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